Abdominal Trauma: Blunt and Penetrating Belly Injuries

First aid for abdominal injuries

1. Call 911 for any significant mechanism (car crash, fall from height, stab or gunshot) or worrying signs.
2. Keep the person lying still, legs raised slightly if there are signs of shock and no spinal injury is suspected. Keep them warm.
3. Do not give food or drink. They may need surgery.
4. For a penetrating wound, press firmly around the wound with a clean cloth. Do not remove a knife or other object stuck in the body; pad around it to keep it still.
5. If organs protrude through a wound, do not push them back. Cover them loosely with a clean, moist dressing or plastic wrap.
6. Watch breathing and responsiveness, and start CPR if they stop breathing normally.

Types of abdominal trauma

Organs at risk and their signs

• Spleen: the most commonly injured organ in blunt trauma. Left upper belly pain, often spreading to the left shoulder tip (Kehr's sign), and signs of blood loss. Risk is higher with an enlarged spleen, such as during mono.
• Liver: right upper belly pain, sometimes right shoulder pain, and bleeding.
• Kidneys: flank pain and blood in the urine after blows to the back or side.
• Bowel: a tear or perforation leaks contents into the abdomen, causing peritonitis with fever and worsening pain over hours to days. Seat-belt injuries are a classic cause.
• Pancreas: upper belly or back pain, often after a handlebar injury in children; signs can be delayed.
• Diaphragm: a tear lets abdominal organs move into the chest, causing breathing difficulty.
• Major blood vessels: rapid, life-threatening bleeding.

The seat-belt sign

A bruise across the lower belly in the shape of a lap belt after a crash means a high-energy force was absorbed by the abdomen. It is linked with bowel injuries and fractures of the lower spine, and always needs a CT scan.

Symptoms of internal injury

• abdominal pain that gets worse rather than better
• tenderness, guarding (tensing when touched) or a rigid belly
• swelling or distension
• bruising on the belly, flanks or around the belly button
• nausea and vomiting, especially with blood
• blood in the urine
• signs of shock: dizziness, fainting, fast heart rate, low blood pressure, pale clammy skin, confusion, fast breathing

Children, older adults, intoxicated people and those with head or spinal injuries may not show clear signs. Bleeding from the spleen can also be delayed by hours or days.

How abdominal trauma is diagnosed

• Primary survey in the ER: airway, breathing, circulation and bleeding control.
• FAST scan (Focused Assessment with Sonography for Trauma): a bedside ultrasound that looks for free fluid (blood) in the abdomen in minutes.
• CT scan with contrast: the main test for stable patients; shows organ tears, bleeding and free air from bowel injury.
• Blood tests: hemoglobin, blood type and crossmatch, liver and pancreatic enzymes, and pregnancy tests.
• Urine test for blood.
• Repeated examination over hours, since some injuries become apparent later.

Treatment

Unstable patients

People in shock with signs of abdominal bleeding go straight to the operating room for exploratory laparotomy, often with damage control surgery: stopping bleeding and contamination quickly, then completing repairs once stable. Blood transfusions are given, and hemorrhagic shock is treated aggressively.

Stable patients

Many blunt injuries to the spleen, liver and kidneys are now managed without surgery:

• close monitoring in hospital with bed rest and repeated blood counts
• angioembolization: a catheter passed through an artery blocks bleeding vessels
• surgery if bleeding continues or a bowel injury is found

Stab wounds may be explored locally, observed, or operated on depending on depth and findings. Most gunshot wounds to the abdomen need surgery.

Recovery

After a spleen or liver injury managed without surgery, contact sports and heavy lifting are usually avoided for several weeks to a few months. People who have the spleen removed need specific vaccines and education about infection risk.

Complications

• delayed bleeding
• infection, peritonitis and abscesses
• pancreatic leaks or pseudocysts
• bowel obstruction from adhesions later in life
• abdominal compartment syndrome, where swelling raises pressure inside the abdomen

Prevention

• Wear seat belts correctly: lap belt low across the hips, not the belly. Use proper car seats and boosters for children.
• Wear protective gear in contact sports and on bikes and ATVs.
• Pregnant people should place the lap belt below the bump and the shoulder belt between the breasts.

Frequently asked questions

What are the signs of internal bleeding after a fall?

Warning signs include worsening belly pain, a swollen or rigid abdomen, bruising on the belly or flanks, pain in the shoulder tip, dizziness or fainting, a racing heart, pale clammy skin and confusion. These need emergency care. Signs can appear hours after the injury.

Can you have an abdominal injury without pain at first?

Yes. Adrenaline, other painful injuries, alcohol or a head injury can mask pain, and some injuries such as bowel tears or delayed spleen bleeding develop over hours. That is why anyone with a high-energy injury should be assessed, even if they feel fine.

What is the most commonly injured organ in blunt abdominal trauma?

The spleen is the most commonly injured organ in blunt abdominal trauma, followed by the liver. Both have a rich blood supply and can bleed heavily. Many such injuries are now treated without surgery under close monitoring.

Do all abdominal injuries need surgery?

No. Many blunt injuries to the spleen, liver and kidneys heal with observation or a catheter procedure to stop bleeding. Surgery is needed for ongoing bleeding with shock, bowel injuries, most gunshot wounds and some stab wounds.

How long after a stomach injury should I watch for symptoms?

Watch closely for at least 24 to 48 hours after a significant blow. Delayed bleeding from the spleen can occur days later, rarely up to a couple of weeks. Seek care immediately for new or worsening pain, dizziness or vomiting.